2021-22 Benefits

Benefits OverviewThe Archdiocese of New Orleans is proud to offer a comprehensive benefits package to eligible full and part-time staff who work a regular schedule of at least 20 hours per week. The complete benefits package is briefly summarized in this booklet. Please visit the ANO Staff Benefits Information page for detailed information on each of these plans. https://nolacatholic.org/ano-staff-benefits-information

Medical Dental Vision Basic Life & AD&D

Short Term Disability Long Term Disability Employee Assistance Critical Illness, Accident

Staff Members who regularly work 20 or more hours per week are eligible to participate in the benefits program on the 1st of the month following date of hire. For some benefits, staff may also choose to enroll eligible dependents.

Eligible dependents for coverage may include:

• Your legal spouse• Your dependent children up to age 26• Disabled dependents of any age (with

appropriate documentation)

Your enrollment choices remain in effect for the benefits plan year, July 1st, 2021 – June 30th, 2022. Deadline to submit changes is: May 28, 2021. Active staff have an open enrollment period each year to make changes to current elections. This year’s open enrollment period is May 17th to May 28th. If you miss the enrollment deadline, you may not enroll in the benefits program until next year unless you have a qualified change in status during the plan year.

Benefit Offerings:

Eligibility:

When Coverage Begins:

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NEWLY HIRED BENEFITS-ELIGIBLE STAFF For newly hired staff who are benefits-eligible, enrollment information will be given to you by your site Administrator. You will need to complete your enrollment online through benefitsCONNECT or by calling the Benefit Advocacy Center as soon as possible, but no later than 30 days from hire. A new hire’s effective date will be the 1st of the month following full time date of hire. Information on how to enroll is found in this guide.

CHANGES DURING THE YEAR You are permitted to make changes to your benefits outside of Open Enrollment if you have a qualified change in status, as defined by the IRS. You must notify the Benefit Advocacy Center within 30 days of the event to make any changes outside of Open Enrollment. Examples include:

• Marriage• Divorce or Separation• Birth or placement for adoption of a child• Death of a spouse or dependent• Loss or gain of dependent’s eligibility• Loss or gain of spouse or dependent’s medical coverage,

through another employer• Change in your employment status or that of your spouse• A qualified domestic relations order or similar court order• Entitlement to Medicare or Medicaid

Topic Contact Phone Number Website & Network General Benef its and/or Enrollment

Benefit Advocacy Center Pam Power Chalana Alexander Landry

833-857-0755504-310-8793504-310-8792

bac.anobenefits@ajg.com ppower@arch-no.org hr@arch-no.org

Medical UMR 800-826-9781 www.UMR.com

Dental Guardian 800-541-7846 www.guardiananytime.com

Vision Guardian (VSP network) 800-877-7195 www.guardiananytime.com or www.vsp.com (provider locator)

Basic L i fe and AD&D Guardian 800-525-4542 www.guardiananytime.com

Short Term Disabi l ity (STD) Guardian 800-268-2525 www.guardiananytime.com

Long Term Disabil ity (LTD) Guardian 800-538-4583 www.guardiananytime.com

Crit ical I l lness / Cancer Guardian www.guardiananytime.com

Accident Guardian www.guardiananytime.com

401(k) Voya 877-659-6995 https://archdioceseno.voyaplans.com

Employee Assistance Program Guardian - (Integrated Behavioral Health) 800-386-7055 www.ibhworklife.com

Continuation of Coverage Blair Barnes @ Gallagher 334-605-1012 Blair_Barnes@ajg.com

BENEFITS CONTACT DIRECTORY

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Once you have made your final decisions about your benefits for 2021, you can log in to the online enrollment system or contact the Benefit Advocate Center to make your elections. Even if you do not want to enroll in any of the benefits, you still need to take action and decline the coverages offered to you. You MUST take action by May 28th.

You have 2 options to enroll in Benefits:

How Do I Enroll?

Option 1:

Enrolling in the online system, benefitsCONNECT

Option 2:

Calling the Archdiocese Benefits Helpline

Once you have made your final decisions about your benefits for 2021, you can log in to the online enrollment system and make your elections. Even if you do not want to enroll in any of the benefits, you still need to log in and decline the coverages offered to you. You MUST take action by May 28th.

Website: https://enroll.benefitsconnect.net/archofno

Username: the first 6 letters of your last name (or your entire last name if six letters or less), the first letter of your first name, followed by the last 4 of your SSN (social security number).

Example: John Johnson, xxx-xx-1234 Username would be johnsoj1234

Password: the first time you log in, the password will be your SSN (no spaces or dashes). You will be given the opportunity to change your password after you log in the first time.

Simply call the Benefit Advocate Center at 1-833-857-0755

You can call between 7 AM – 6 PM CST

You may also email them at @ bac.anobenefits@ajg.com

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Health Plan Whether you have a common cold or will be undergoing surgery, medical benefits cover a range of services and can provide peace of mind to help you offset heath care costs. The Archdiocese of New Orleans offers you the following medical plan options through UMR (A United Healthcare Company). NEW: UMR and Ochsner Health Network have partnered to bring our members a new product that provides quality care at an affordable price. Find the BLUE to see what cost savings you can have when visiting Ochsner!

Benefit Plan 1 Plan 2 Plan 3 Plan 4

Ochnser In-Network Ochsner In-Network Ochsner In-Network Ochnser In-Network

Annual Deductible Single

Family

None None

$600 $1,800

$750 $2,250

None None

None None

$400 $1,200

$500 $1,500

Annual Out of Pocket Maximum

Single Family

$3,250 $6,500

$4,000 $8,000

$3,000 $6,000

$2,750 $5,500

Hospitalization

Emergency Room $350 $350 $350 20% after deductible

Inpatient Stay $400 Copay $500 Copay 10% after deductible

20% after deductible

$150 Copay $200 Copay 10% after deductible

20% after deductible

Outpatient Surgery

$400 Copay $500 Copay 10% after deductible

20% after deductible

$150 Copay $200 Copay 10% after deductible

20% after deductible

Office Visits

Primary Care Specialist

Urgent Care Wellness

$25 Copay $35 Copay $35 Copay Covered

$30 Copay $45 Copay $45 Copay Covered

$25 Copay $35 Copay $35 Copay Covered

$30 Copay $45 Copay $45 Copay Covered

$15 Copay $25 Copay $35 Copay Covered

$20 Copay $35 Copay $45 Copay Covered

$25 Copay $35 Copay $35 Copay Covered

$30 Copay $45 Copay $45 Copay Covered

Prescription Drugs

Deductible* Single/Family

Copays: Generic

Preferred Brand Non-Preferred

Specialty

$100/ $200

$7

$30 $70

10% (max of $150)

$250 per person

$7

$30 $70

10% (max of $150)

$100 / $200

$7

$30 $70

10% (max of $150)

$100 / $200

$7

$30 $70

10% (max of $150) *Prescription deductible applies to brand name drugs only, no deductible applied to generics

Health Plan Rates: All staff contribute to the cost of health coverage; view your payroll deduction in the benefitsCONNECT enrollment system or please contact your site administrator

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You Can Now Save by Visiting an Ochsner Provider or Facility!

UMR and Ochsner Health Network have partnered to bring our members a new product that provides quality care at an affordable price.

Ochsner Select Plus is an open access, tiered product that promotes the value of a PCP and the care coordination that can bring to you overall care.

Ochsner Medical Center – Main Campus Ochsner Medical Center – Baptist Campus

Ochsner Medical Center Kenner Ochsner Medical Center Westbank

Ochsner Medical Center Northshore Ochsner Hospital for Orthopedics & Sports

Ochsner Medical Center Baton Rouge Ochsner St. Ann Hospital (Raceland) Ochsner St. Bernard Parish Hospital Ochsner St. Charles Parish Hospital

Ochsner St. Mary Parish Hospital Leonard J Chabert Medical Center (Houma)

Slidell Memorial Hospital St. Tammany Parish Hospital

Go to UMR.com, Find a Provider, UnitedHealthcare Louisiana Select Plus Tiered, Search, Find the Green Button - View Providers, Enter a ZipCode or City. Where you go for care can make a difference!

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FAQ’s on The New Ochsner Tier Savings: Q: I prefer to stay with my current Dr’s who aren’t at Ochnser. Will there be any changes or penalties to my existing plan? A: No, all our current plans will remain the same. UMR has teamed with Ochsner to offer cost savings for those who choose to see an Ochsner Provider or Facility. You are welcome to see anyone you like, and there will be no changes to your existing In-Network benefits.

Q: I am on plan that has a deductible. I see there’s a deductible for Ochsner and a deductible for In-Network, do I have to meet both deductibles if all my care isn’t at Ochsner? A: No, the Ochsner deductible applies toward the In-Network deductible. The maximum you will pay toward your deductible is found within the in-network tier as listed in the benefit grid above.

Q: I see an Ochnser Physician today. When will the less expensive Copays start for me? A: This new partnership with Ochsner begins July 1 for members of The Archdiocese of New Orleans. You will receive new ID Cards prior. Make sure your Physician has a copy of the newest ID.

Q: I am scheduled to have a surgery at an Ochsner Hospital. Am I required to have an Ochnser Primary Care Physician in order to have the incentive? A: No, the facility alone with trigger the lesser expense. You are not required to have an Ochsner Primary Care Physician to drive your care.

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Dental Benefits Administered by Guardian

PLAN OVERVIEW Basic Low Plan Preferred High Plan

Annual Deductible $50 Individual $50 Individual $150 Family $150 Family

Annual Benefit Maximum $1,250 per person $1,250 per person

COINSURANCE

Preventive Services Oral Exams Cleanings – Once every 6 months Bitewing X-Rays – Once every 12 months

Covered at 100%

Covered at 100%

Basic Services Fillings X-Rays other than Bitewings- once every 60 Months Minor Oral Surgery & Simple Extractions Palliative Treatment Periodontics Treatment

Covered at 80% after deductible

Covered at 80% after deductible

Major Services Inlays, Onlays, & Veneers Bridges & Dentures Single Crowns

Not Covered

Covered at 50% after deductible

ORTHODONTIA

Orthodontia Services (dependent children only to age 19)

Not Covered Covered at 50% after deductible

Lifetime Benefit Maximum Not Covered $1,000 Lifetime Max

Employee Contribution (Monthly)

Low Plan High Plan

Employee $13.69 $27.27

Employee + One $26.98 $52.83

Employee + 2 or more dependents $50.42 $92.43

Dental benefits are another important element of your overall health. You have a choice of two plans: Basic Low Plan or Preferred High Plan. Both plans are PPO plans, designed to give you the freedom to receive dental care from any licensed dentist of your choice. Both plans offer Maximum Rollover, so you can earn rollover dollars, if you accumulate less than the threshold. Check your Guardian portal for your balance!

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Vision Benefits Administered by Guardian (VSP network)

Vision coverage is offered by Archdiocese of New Orleans. By practicing healthy eye habits, you and your family members can work toward preserving your vision for the long haul.

Plan Overview

Frequency In Network Member Cost Out of Network Benefit

Vision Exam Every 12 months $10 Copay Up to $50

Lenses Single Lined Bifocal Lined Trifocal Lenticular

Every 12 months

Covered by Copay Covered by copay Covered by copay Covered by copay

Up to $48 Up to $67 Up to $86 Up to $126

Frames Every 24 months $130 allowance for frames of your choice and 20% off the amount over allowance. Up to $48

Elective Contact Lenses *Contact Lenses are in place of lenses and frames

Every 12 months Up to $130 allowance Up to $120

Employee Contribution (Monthly)

Employee $7.81

Employee + Spouse $15.60

Employee + Children $17.16

Employee + Family $25.03

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Accident Insurance Administered by Guardian

Even minor accidents can leave you with major expenses. When accidents happen, they are often followed by a number of bills. Are you prepared? Accident Expense insurance plan pays a cash benefit directly to you in addition to any other benefit or insurance you receive. Even with medical insurance, you still have to meet deductibles and pay for coinsurance. There may be additional costs due to emergency room fees, x-rays, follow-up care and other uncovered services. This plan can help you pay for these and other covered expenses. For example, accidents as a result of these activities may be covered by this policy: Football, Baseball, Basketball, Soccer, Tennis, Volleyball, Paintball, Mountain Biking, Motorcycle Riding, Cheerleading, Skateboarding, Automobile Accidents, Hunting, and Boxing Key features to consider:

Guarantee Issue upon New Hire Period

Pays direct to policyholder to assist with out-of-pocket expenses

Pays in addition to medical insurance benefits

Most sports and extracurricular activities are covered (see policy limitations)

Coverage available for the entire family

Fully Portable

Rate Table per Month

Employee Only $13.27

Employee + Spouse $22.20

Employee + Child(ren) $22.73

Family $31.66

Commonly Utilized Benefits

Benefit Description Amount

Dr. Appointment Physician or Urgent Care Visit due to Accident $150 Physician, $150 Urgent Care

Ambulance Ground or air transportation

$150 Ground, $1,000 Air

Hospital Admission Payable when confined for covered accident – Minimum of 24 hours per person

$1,000, $2,000 ICU

Hospital Confinement Payable when confined for covered accident – Minimum of 24 hours per person

$225 per day, $450 per day ICU

Fracture Based on schedule Up to $8,000

Dislocation Based on schedule Up to $6,000

Wellness $50 for Employee and Spouse per calendar year $50

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Critical Illness Administered by Guardian

You may know people who have been affected by a critical illness such as cancer, stroke or heart attack, and witnessed the impact it had on their quality of life. Are you prepared if a critical illness were to happen to you? Critical Illness insurance can help you when you need it the most. It provides a valuable benefit should you or your family be faced with bills resulting from a critical illness. This benefit is in addition to your medical insurance. It helps fill the financial gaps left by deductibles, coinsurance and other out-of-pocket expenses. The Guardian Critical Illness lump sum policy payment upon diagnosis include:

Cancer (Internal or Invasive) 100% Vascular 100%

Heart Attack (Myocardial Infraction) 100% Benign Brain Tumor 100%

Stroke 100% Organ Failure 100%

Kidney Failure (End Stage Renal) 100% Carcinoma In Situ 30%

Major Organ Transplant 100% Skin Cancer $250

Severe Burn 100% Coma 100%

Paralysis 100% Loss of Sight, Speech, Hearing 100%

Other Conditions

Cystic Fibrosis 50% Cerebral Palsy 50%

Cleft Lip or Cleft Palate 50% Down Syndrome 50%

PKU Disease 50% Spina Bifida 50%

Type 1 Diabetes 50% Autism Spectrum Disorder $3,000

MONTHLY PREMIUM

Employee Amounts Benefit <30 30-39 40-49 50-59 60-69 70+ $10,000 $4.90 $6.60 $12.80 $24.40 $42.80 $78.40 $20,000 $9.80 $13.20 $25.60 $48.80 $85.60 $156.80

Spouse Benefit

<30 30-39 40-49 50-59 60-69 70+

$5,000 $2.45 $3.30 $6.40 $12.20 $21.40 $39.20 $10,000 $4.90 $6.60 $12.80 $24.40 $42.80 $78.40

Features: • Benefits are paid directly to you, unless otherwise assigned. • Coverage is available for you, your spouse, and dependent children. • Coverage may be continued (with certain stipulations). That means you can take it

with you if you change jobs or retire. • Fast claims payment. Most claims are processed in about 4 days. • Additional Diagnosis: We will pay benefits for each different critical illness after the

first when the two dates of diagnoses are separated by at least 6 consecutive months. Cancer diagnoses are subject to the cancer diagnosis limitation

• Reoccurrence: We will pay benefits for the same critical illness after the first when the 2 dates of diagnoses are separated by at least 6 consecutive months. Cancer diagnoses are subject to the cancer diagnosis limitation.

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Basic Life & Accidental Death & Dismemberment Insurance Administered by Guardian

Supplemental Life & Accidental Death & Dismemberment

Only NEW HIRES may purchase life and AD&D insurance in addition to the company provided coverage until 2022. You may also purchase life and AD&D insurance for your dependents through Guardian.

Employee—$150,000 maximum amount; increments of $25,000.

Spouse.- A maximum of $25,000

Children—A maximum of $10,000

Employee Voluntary Life and AD&D Election Choices & Monthly Premiums Age Bracket $25,000 $50,000 $75,000 $100,000 $150,000

Employee Spouse < 30 $2.00 $2.00 $4.00 $6.00 $8.00 $12.00

30 – 34 $2.25 $2.25 $4.50 $6.75 $9.00 $13.50 35 – 39 $2.75 $2.75 $5.50 $8.25 $11.00 $16.50 40 – 44 $4.00 $4.00 $8.00 $12.00 $16.00 $24.00 45 – 49 $6.25 $6.25 $12.50 $18.75 $25.00 $37.50 50 – 54 $9.50 $9.50 $19.00 $28.50 $38.00 $57.00 55 – 59 $14.25 $14.25 $28.50 $42.75 $57.00 $85.50 60 – 64 $19.75 $19.75 $39.50 $59.25 $79.00 $118.50

65 – 69* $18.69 $28.75 $37.38 $56.06 $74.75 $112.13 70 – 74* $20.20 $50.50 $40.40 $60.60 $80.80 $121.20 75 – 79* $12.63 $12.63 $25.25 $37.88 $50.50 $75.75

$10,000 Child Rate $1.00

Life insurance provides financial security for the people who depend on you. Your beneficiaries will receive a lump-sum payment if you should die while employed by Archdiocese of New Orleans. Archdiocese of New Orleans provides, at no cost to you, a 2.5 annual earnings, up to a maximum of $200,000. Age Reductions: 35% at age 65, 60% at age 70, 75% at age 75, and 85% at age 80. Accident Accidental Death and Dismemberment (AD&D) insurance provides payment to you or your beneficiaries if you lose a limb or die in an accident.

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Short-Term Disability Insurance

Insured by Guardian

Should you experience an illness or injury that prevents you from working, disability coverage acts as an income replacement to protect important assets and help you continue with some level of earnings. Benefits eligibility may be based on disability for your occupation or any occupation. The Archdiocese of New Orleans provides Short Term Disability and Long Term Disability coverage through Guardian at no cost to you

- Benefits begin on the 30th day after your disability and can continue for up to 9 weeks. - Weekly Benefit Amounts - 60% of weekly covered earnings - Benefit Maximum – up to $1,000 per week

Long-Term Disability Insurance Insured by Guardian

Meeting your basic living expenses can be a real challenge if you become disabled. Your options may be limited to personal savings, spousal income and possibly Social Security. Disability insurance provides protection for your most valuable asset—your ability to earn income. Archdiocese of New Orleans offers long term disability coverage which provides income when you have been disabled for more than 90 consecutive days. Your benefit is 60% of your monthly earnings, up to $4,000 per month.

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Employee Assistance Program Administered by Guardian Life’s unpredictable – sometimes it can throw you a curveball. That’s why it’s important to know there’s help available when you need it. Your Employee Assistance Program (EAP), sponsored by Archdiocese of New Orleans, gives you access to resources you can turn to when the challenges of life are getting the best of you. Things like relationship issues, anxiety, addiction, aging parents to care for. They can all make balancing work and life stressful. This free service is completely confidential, your Archdiocese of New Orleans Leadership Team will never know who calls the EAP.

WorkLifeMatters Employee Assistance Program offers services to help promote well-being and enhance the quality of life for you and your family. This free service is available to benefit-eligible staff members enrolled in the employer-paid Guardian life or disability products.

Support and guidance is available online for assistance with family and personal issues at www.ibhworklife.com and by phone at 1-800-386-7055.

WorkLifeMatters Employee Assistance Program

Connec t to a couns elor for f ree s upport serv ices!

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Extra Benefits As a benefits-eligible employee, there are several additional benefits available to you that serve as a supplement to your core coverage.

UMR & Your Mobile Device Mobile Portal

As a UMR member, you can access your benefit and claim information anytime using your mobile device. There’s no app to download. Simply log in to umr.com on your smart phone using the same username and password you use for our full site. You can: • Find a provider on the go • Look up claims for yourself or an authorized dependent • View, scan or fax your ID card • Check your benefits

Teledoc

UMR has partnered with Teladoc to offer anytime access to a national network of U.S. board-certified physicians. Members can connect with network physicians for telephonic or face-to-face, online video consultations 24 hours a day, 365 days a year. Teladoc’s network of state-licensed primary care physicians can diagnose routine, non-emergency, medical problems, recommend treatment and prescribe short-term, non-DEA-controlled medications, when needed. For more information, visit www.teledoc.com or call 800-835-2362.

UMR DISEASE MANAGEMENT

UMR invites members with chronic health conditions to enroll in coaching with their team of chronic care professionals.

Through a series of one-on-one coaching calls, our registered nurse coaches educate and empower members to effectively manage their condition and improve their quality of life. The

program is available to members with conditions such as diabetes, hypertension, asthma and more.

Guardian's TravelAid

Whether you are one hundred or thousands of miles away from home, TravelAid provides a combination of global travel assistance services: • Prevention before travel: Before leaving home, you can get travel alerts and destination information, pre-travel immunization information, international medical insurance and claims administration and travel medical kits.

• Emergency response: Get access to 24/7 multilingual assistance for help with travel arrangements, lost documents and replacement of prescriptions and credit cards.

• Worldwide physician and hospital referrals: Receive guidance on doctors, dentists, hospitals and facilities, multilingual services at medical facilities and patient accommodations.

• Medical transportation: Along with responsive service, the latest equipment and technology are provided.

• Specialized security resources: Embassy and consular assistance is available. Personnel are experienced in handling sensitive and complex emergency security situations.

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Extra Benefits

PARENTAL BONDING LEAVE If you are a new mom or dad, congratulations! We know how precious those first weeks are in order to get to know your new bundle of joy. That is why we now offer parental bonding leave to all benefits-eligible staff at our parishes and parish schools, administrative offices, programs and ministries and entities owned and/or operated by the Archdiocese.

Here’s how it works: • Benefit: 100% of pay for up to six weeks.

• Please request time off from your supervisor 30 days before the birth or placement through adoption/foster

care of your child. • Your location will approve your leave.

• If both parents work for the same location, each may take a separate parental bonding leave of absence at

alternate times, as determined by the location’s director and the employees’ appropriate supervisor(s).

COLLEGE TUITION BENEFIT: A SCHOLARSHIP PROGRAM

This plan helps Guardian-enrolled dental members save money for college. With the College Tuition Benefit, you earn 2,000 tuition

rewards points for every year you’re a Guardian Dental member, plus bonuses.

Register Online by visiting www.Guardian.CollegeTuitionBenefit.com (Use Group ID # 538205, Password: Guardian).

UMR Maternity Management UMR’s maternity management program provides information and coaching to women considering having a child, prenatal education and guidance to those expecting, and high-risk pregnancy identification to help expectant mothers carry their babies to term. Members may self-enroll online at umr.com or by calling the toll-free number on their medical ID card. All members who join the maternity management program during their first or second trimester are eligible to receive a gift of their choice. Participants may choose from a selection of high-quality books and other materials containing helpful information about pregnancy, pre-term labor, childbirth, breastfeeding and infant care. Members who enroll during their first or second trimester and successfully complete the program are eligible to receive a UMR-funded $25 gift card.

QUIT WITH US, LA The Smoking Cessation Trust Management Services (SCTMS) can arrange for you to receive FREE cessation assistance with: doctor

visits, group counseling, telephone support, and more. Visit www.smokefreela.org for more. 16

RETIREE POLICY effective 7/1/2004 Eligibility Requirements – In order to qualify for the retiree benefits an employee must have fifteen (15) years of continuous service with The Archdiocese, and be between the ages of 55 and 65. The benefits are for the retiree and their qualified dependents. The retiree and his/her dependents must be enrolled on The Archdiocese’s health plan at the date of retirement. Eligibility in this plan will cease upon Medicare eligibility of the retiree. Upon Medicare eligibility of the retiree, the dependents only (if not eligible for Medicare) will be offered continuation of coverage. If a dependent becomes eligible for Medicare before the retiree, the benefits will cease upon eligibility for the dependent, but will still be available for the retiree if not yet eligible. Only dependents at the time of the retirement are allowed to participate. No future dependents can be added no matter the circumstances. If an employee meets those requirements, he or she may participate in the retiree plan. Any pre-existing condition restrictions (if applicable) by the health carrier would apply. Effective Date of Benefits – If the retiree meets the basic requirements, the effective date of retiree benefits will be the first date of the month following date of retirement. Eligibility Notification – It is the retiree’s responsibility to communicate to the employer site, their intent to apply for retiree benefits. The retiree will be required to submit to the employer site (last employed) in writing the retirees intent to elect retiree benefits. The retiree will also be required to fill out the proper paperwork required to submit to the health carrier in order for the health carrier to receive the required forms within 30 days of the retiree date. Any forms submitted after this time will forfeit the retiree’s rights to benefits. Duration of Eligibility – Eligibility for retiree health benefits lasts until Medicare eligibility for the retiree. If the retiree has dependents then continuation will be available under the requirements of continuation. (See Continuation of Coverage Policy) The Archdiocese reserves the right to alter or amend the retiree benefits. The benefits could also be terminated at the discretion of the Archdiocese if retiree benefits significantly impact benefits for the active employees. Work after Retirement – Should a retiree re-qualify for eligibility in the Archdiocese’s active health plan on the basis of hours worked after the date of retirement, the retiree will be transferred to the active health plan for full benefits on the first date of the subsequent eligibility period. When the retiree is considered no longer an active employee, the retiree will be immediately returned to the retiree health plan until Medicare eligible. Surviving Dependents of Retirees – any surviving dependents of retirees will be offered continuation of coverage for a maximum duration of 12 months as specified under the provisions of continuation of coverage.

CONTINUATION OF COVERAGE POLICY effective 7/1/2004 Continuation shall only be available to an employee or dependent who has been continuously insured under the group policy, or for similar benefits under any other group policy that it replaced, during the period of three consecutive months immediately prior to the date of termination. (Continued on next page)

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Continuation shall not be available for any person who is or could be covered by any other arrangement of hospital, surgical, medical coverage for individuals in a group or eligible for Medicare, within 31 days immediately following the date of termination, or whose insurance terminated because of fraud or because he failed to pay any required contribution for the insurance, or who is eligible for continuation under the provisions of the Consolidated Omnibus Budget Reconciliation Act of 1987 (COBRA). Continuation rights will not apply to dental, vision, or any other benefits provided under the group policy in addition to its hospital, surgical, or major medical benefits. An employee or dependent electing continuation shall pay to the group policyholder or his employer, in advance, the amount of contribution required by the policyholder or employer, but not more than the full group rate for the insurance applicable to an active employee or dependent under the group policy on the due date of each payment. The employee or dependent shall not be required to pay the amount of the contribution less often than monthly. In order to be eligible for continuation of coverage, the employee or dependent shall make a written election of continuation, on a form furnished by the group policyholder, and pay the first contribution, in advance, to the policyholder or employer on or before the date on which the employee’s or dependent’s insurance would otherwise terminate. Such form shall be as prescribed in this Section. Continuation of insurance under the group policy for any person shall terminate on the earliest of the following dates:

• The date 12 months after the date of the employee’s or dependent’s insurance under the policy would otherwise have terminated because of termination of employment or membership.

• The date ending the period for which the employee or dependent last makes his required contribution, if he discontinues his contributions.

• The date the employee or dependent becomes or is eligible to become covered for similar benefits under any arrangement of coverage for individuals in a group the date on which the group policy is terminated

The qualifying events for employees are: • Voluntary or involuntary termination of employment; or reduction in the number of hours of

employment, resulting in a loss of coverage under the policy

The qualifying events for spouse are: • Voluntary or involuntary termination of the covered employee’s employment; • Reduction in the hours worked by the covered employee, resulting in a loss of coverage under the

policy; • Covered employee’s becoming entitled to Medicare; • Divorce from the covered employee; or • Death of the covered employee

The qualifying events for dependent children are: • Loss of “dependent child” status under the plan rules; or • Death of the covered employee

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Annual Notices & Disclosures Important Notice from Archdiocese of New Orleans About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Archdiocese of New Orleans and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. Archdiocese of New Orleans has determined that the prescription drug coverage offered by the company is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join a Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two- (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens to Your Current Coverage if You Decide to Join a Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Archdiocese of New Orleans coverage will be affected. See plan SPD for more information about your prescription drug coverage provisions/options.

If you do decide to join a Medicare drug plan and drop your current employer-sponsored coverage, be aware that you and your dependents will be able to get this coverage back.

When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with Archdiocese of New Orleans and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information About This Notice or Your Current Prescription Drug Coverage…

Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Archdiocese of New Orleans changes. You also may

For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: • Visit www.medicare.gov

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• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help

• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. • If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information

about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Date: 7/1/2021 Name of Entity/Sender: Archdiocese of New Orleans Contact: Pam Powers Phone Number: 504-310-8793 HIPAA Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

To request special enrollment or obtain more information, contact Pam Powers at 504-310-8793

HIPAA Privacy Notice - Protecting Your Health Information Privacy Rights Archdiocese of New Orleans is committed to the privacy of your health information. The administrators of the Archdiocese of New Orleans insurance plan (the “Plan”) use strict privacy standards to protect your health information from unauthorized use or disclosure.

The Plan’s policies protecting your privacy rights and your rights under the law are described in the Plan’s Notice of Privacy Practices. You may receive a copy of the Notice of Privacy Practices by contacting Pam Powers at 504-310-8793

Women’s Health and Cancer Rights Act Initial Notification If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

• All states of reconstruction of the breast on which the mastectomy was performed; • Surgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses; and • Treatment of physician complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under the plan. Therefore, your deductible and coinsurance apply as according to your employer-sponsored medical insurance plan.

If you would like more information on WHCRA benefits, call your plan administrator Pam Powers at 504-310-8793

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

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If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

To see if any other states have added a premium assistance program since January 31, 2017, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services

Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

OMB Control Number 1210-0137 (expires 12/31)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2017. Contact your State for more information on eligibility-

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

LOUISIANA – Medicaid NEW YORK – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

Website: https://dma.ncdhhs.gov/ Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-462-1120

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP Website: http://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/medical-assistance.jsp Phone: 1-800-657-3739

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MISSOURI – Medicaid OREGON – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – Medicaid Website:http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Website:http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – Medicaid Website:http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebraska_index.aspx Phone: 1-855-632-7633

Website: http://www.eohhs.ri.gov/ Phone: 401-462-5300

NEVADA – Medicaid SOUTH CAROLINA – Medicaid Medicaid Website: https://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900

Website: https://www.scdhhs.gov Phone: 1-888-549-0820

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ALABAMA – Medicaid FLORIDA – Medicaid

Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://dch.georgia.gov/medicaid - Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507

ARKANSAS – Medicaid INDIANA – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864

COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) IOWA – Medicaid

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711

Website: http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp Phone: 1-888-346-9562

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